(Company name)

IMO CREW LIST

(IMO FAL Form 5)

Page Number

Arrival Departure
1.1 Name of ship 1.2 IMO number

1.3 Call sign 1.4 Voyage number

2. Port of arrival/departure 3. Date of arrival/departure

4. Flag state of ship 5. Last port of call

6 No. 7. Family name, given names 8. Rank or rating 9. Nationality 10. Date and 11. Nature and
place of birth number of identity
document

12. Date and signature by master, authorized agent or officer

 Republic of the Philippines

Office of the President

COMMISIION ON HIGHER EDUCATION

Department of Transportation and Communications

MARITIME INDUSTRY AUTHORITY

CERTIFICATE OF SEA SERVICE

Sir / Madam :

This is to certify that holder of SIRB No. has

been employed by this company with the following sea going service/s:

Name of Type Route Gross KW Registry Period Covered Position / Total Sea
Vessel (Foreign / Tonnage Power From To Rank service
Domestic) Y/M/D Y/M/D Y-M-D

This further certifies that the above-stated data are true and that any false statement/s made herein
shall be ground for criminal prosecution.

Issued this day of at .

COMPANY SEAL
President / Duly Authorized Person
Signature above Printed Name

SUBSCRIBED AND SWORN to before me this day of , 20 ,

Doc No. :
Page No. :
Book No. :
Series of : Notary Public

Note:
This form is good only for one (1) vessel. This form can be reproduced. Any erasure / obliteration may be a ground for denial.